location: al-qanawis, hodeidah, yemen date: september 2013 ... · cmam periodically by community...

LOCATION: Al-Qanawis, Hodeidah, Yemen DATE: September 2013 NAME: SANJAY KUMAR DAS

SQUEAC Assessment Report of Al-Qawanis, Hodeidah, Yemen, September 2013 2

ACKNOWLEDGEMENTS

Save the Children International (SCI) would like to thank the following organizations

and persons without whose support the objectives would not have been achieved:

UNICEF for financial assistance and Coverage Monitoring Network (CMN) for

facilitating Semi-quantitative evaluation of Access and Coverage (SQUEAC)

assessment and on-the-job training to SCI and other partner staffs

Ministry of Public Health and Population (MOPHP) and local partner NGOs for

their on-going support during SQUEAC assessment in Al-Qanawis district

Al-Qanawis community for allowing the investigation to be carried out on their

territory

Special thanks go to the local authority, parents, Community Outreach Workers

(COW), village leaders, drivers and community guides for their valuable

information and time.

The entire assessment team for their high level of commitment and cooperation

in all stages of the training and investigation process.


ACRONYMS

ARI: Acute Respiratory Infection

ARRA: Administration for Refugees and Returnees Affairs

BSFP: Blanket Supplementary Feeding Program

CDR: Crude Death Rate

CI: Credibility Interval

CMAM: Community Based Management of Acute Malnutrition

CM: Community Mobilizers

CMN: Coverage Monitoring Network

COW: Community Outreach Workers

DNA: Did Not Attend

ECHO: European Commission's Humanitarian Office

FGD: Focus Group Discussion

GAM: Global Acute Malnutrition

GBV: Gender Based Violence

IYCF: Infant and Young Child Feeding

KII: Key Informant Interview

MAM: Moderate Acute Malnutrition

MOPHP: Ministry of Public Health and Population

MUAC: Mid-Upper Arm Circumference

OTP: Outpatient Therapeutic Programme

PLW: Pregnant and Lactating Woman

SAM: Severe Acute Malnutrition

SC: Stabilization Centre

SCI: Save the Children International

SQUEAC: Semi Quantitative Evaluation of Access and Coverage

TBA: Traditional Birth Attendants

TSFP: Targeted Supplementary Feeding Program

U5MR: Under Five Mortality Rate

UN: United Nation

UNICEF: United Nations Children’s Fund


EXECUTIVE SUMMARY Yemen is one of the poorest countries in the Middle East / North Africa region and ranks

154 on the Human Development Index1. High levels of poverty and poor education and

health outcomes have been further exacerbated by years of unrest and insecurity due to

on-going conflict with the Houthi insurgents in northern Yemen. With the support of

UNICEF grant, SCI in close collaboration of MOPHP has been implementing emergency

nutrition interventions in four districts namely Aluhyah, Al Qanawis, Al Meghlaf, and Al

tuhaita located in Hodeidah Governorate since October 2012. The program is intended

to benefit acutely malnourished children and pregnant and lactating mothers

The objectives of this assessment were to determine the coverage of the out-patient

therapeutic program (OTP) in Al-Qawanis district of Hodeidah, to identify barriers and

boosters to coverage and to build the capacity of SCI and partner’s staffs so that

coverage assessment can be done regularly as part of program monitoring system.

SQUEAC methodology was used for coverage assessment and house to house survey

technique was used to identify malnourished cases in the community.

Findings from the assessment indicated 61.6percent (CI 50.9%-71.0%) point coverage

for OTP. OTP coverage is above SPHERE minimum standard for rural setting and the

program displayed some clear strengths and good practices. The main reason for this

level of coverage is due to decentralized CMAM services, strong community

mobilization network and community participation. This decentralization has

contributed to better access, rapid distribution of rations and decreased waiting times

in OTP for beneficiaries. They are also disseminating key messages of malnutrition and

CMAM periodically by community outreach workers. The major barriers to coverage

were distance and inadequate community mobilization in some villages. Median MUAC

on admission was 11 cm which indicates early case finding and admission in the

program. Median length of stay for cured children was 6 weeks but some children had

stayed for more than 12 weeks. There were very few defaulters and main reason for this

was because COWs carried RUTF to the homes of absent SAM children.

Programs should focus on community sensitisation especially in faraway villages.

Coordination with local governments and UNICEF should be strengthened for adequate

supply of RUTFs, routine medicines and rearrangement of some catchment areas to

nearby OTPs. The waiting area should be safe and mass screening should be conducted

quarterly to increase coverage of the program.

1 UNDP Human Development Index 2011, http://hdr.undp.org/en/statistics/

http://hdr.undp.org/en/statistics/#_blank


CONTENTS ACKNOWLEDGEMENT……………………………………………………………………………………………………….2

ACRONYMS………………………………………………………………………………………………………………………..3

EXECUTIVE SUMMARY……………………………………………………………………………………………………….4

1. INTRODUCTION ………………………………………………………………………………………..6

1.1 CONTEXT…………………………………………………………………………………………………………..6

1.2 CMAM PROGRAMMES IN THE AREA……………………………………………………………..........7

2. OBJECTIVES………………………………………………………………………………………………….. 8 2.1 GENERAL OBJECTIVE .......................................................................................................................... 8

2.2 SPECIFIC OBJECTIVE ........................................................................................................................... 8

2.3 EXPECTED OUTPUT ............................................................................................................................. 8

3. METHODOLOGY .............................................................................................................................. 9 3.1 SQUEAC ......................................................................................................................................................... 9 3.2 DURATION OF ASSESSMENT ............................................................................................................... 9 3.3 PARTICIPANTS ......................................................................................................................................... 10

4. RESULTS ................................................................................................................................................... 10 4.1 QUANTITATIVE DATA ANALYSIS .................................................................................................... 10 4.2 QUALITATIVE DATA ANALYSIS ........................................................................................................ 15 4.3 SMALL AREA SURVEY/STUDY .......................................................................................................... 18 4.4 WIDE AREA SURVEY…………………………………………………………………………………………..19

5. DISCUSSION ......................................................................................................................................... 25

6. RECOMMENDATIONS ............................................................................................................ 26

ANNEX ANNEX 1: VILLAGE LIST-SAMPLING FRAME .................................................................................................. 28

ANNEX 2: EVALUATION TEAM............................................................................................................................... 30

ANNEX 3: ACTIVE ADAPTIVE CASE FINDING PROCEDURE...…………………………………………….31

ANNEX 4: QUALITATIVE DATA COLLECTION GUIDELINE ..................................................................... 33

ANNEX 5: QUESTIONNAIRE FOR SAM NOT IN PROGRAM ....................................................................... 48


INTRODUCTION

1.1 CONTEXT Yemen is one of the poorest countries in the Middle East / North Africa region and ranks

154 on the Human Development Index2. High levels of poverty and poor education and

poor health outcomes have been further exacerbated by years of unrest and insecurity

due to on-going conflict with the Houthi insurgents in northern Yemen. Over the past

several years, hundreds of thousands of Yemenis have been forced to flee violence,

seeking refuge in IDP camps. A protracted IDP situation continues to date, with a high

concentration of displacement in the north including Amran, Al Jawf and Hajjah

governorates.

According to the World Food Program (WFP) report on State of Food Security and

Nutrition in Yemen, which released a comprehensive food security survey report in

May, 2012, over 5 million people (22% of the population) of Yemen are severely food

insecure and are unable to produce or buy the food they need. An additional five million

people were found to be moderately food insecure and at risk of becoming severely food

insecure in the face of rising food and fuel prices and conflict. Yemen’s Global Acute

Malnutrition (GAM) rate is reaching alarming levels in many parts of the country. As per

the UNICEF/MoPHP nutrition assessments conducted in Hodeidah (December 2011)

and in Hajjah (May 2012) the rate of GAM was estimated at 31.7percent and

21.6percent respectively3.

The infant and young feeding (IYCF) situation in Yemen is extremely poor. Nationally,

only 12percent of infants less than six months of age are exclusively breastfed and the

rate of early initiation of breastfeeding is 30percent. The IYCF and Wash baseline

surveys were conducted in Hodeidah Governorate by Save the Children shows

extremely poor IYCF practice. According to this survey the prevalence of bottle feeding

is very high (36.8%), only 13.6percent of infants less than 6 months are exclusively

breast fed and only 48.4percent of children are put on the breast within one hour after

delivery.

1.2 CMAM PROGRAMME IN Al-Qanawis District

With the support of UNICEF grants, SCI in close collaboration with MOPHP has been

implementing emergency nutrition interventions in four districts namely Aluhyah, Al

Qanawis, Al Meghlaf, and Al Tuhaita located in Hodeidah Governorate since October

2 UNDP Human Development Index 2011, http://hdr.undp.org/en/statistics/

3 World Food Program. ‘The State of Food Security and Nutrition in Yemen’. 2012

http://hdr.undp.org/en/statistics/#_blank


2012. The program is intended to benefit acutely malnourished children and pregnant

and lactating mothers. The components of this program include outpatient therapeutic

program (OTP) for SAM without complications, stabilization centre (SC) for SAM with

medical complications, targeted supplementary feeding programs (TSFP) for moderate

acute malnutrition (MAM) and community outreach activities. The project period for

the UNICEF grant is from October 2012 to September 2014. The plan is to hand over

the project to MOPHP by March, 2014 and to provide minimal support up to September,

2014. This SQUEAC investigation covers Al Qanawis district. The total population of the

Al-Qanawis is 44383. There are 11 main villages and 56 sub-villages in the district.

There are 11 OTPs in health facilities (HFs) and teams set up 7 satellite OTP sites in

villages far away from HFs to have better access and coverage of the program. The

program is implemented through two mobile nutrition teams and Al-Qanawis

government health workers. SCI mobile teams and MOPHP staffs are working together

in OTP sites to enhance the capacity of MOPHP staffs but the challenges are that there

are not sufficient MOPHP staffs in some OTP sites and some OTP sites do not have

adequate infrastructure. These are the issues for discussion before handover of OTP in

March 2014 to MOPHP. There are five community outreach workers (COWs) in each

OTP catchment areas and they are responsible for case finding, nutrition counselling,

referral and follow up visits.

The Nutrition program of Al-Qanawis is managed by two mobile teams each team

composed of 1 team leader, 2 nutrition nurses and 5 COWs. The two mobile teams get

support from qualified and well experienced staffs at governorate level which are

composed of Nutrition Program Manager, Health and Nutrition Coordinator, HIS Officer,

Nutrition officer and community mobilization officer.


Fig1 Organogram of Al-Qanawis Nutrition Program

1. OBJECTIVES

2.1 GENERAL OBJECTIVE

To conduct a coverage assessment of out-patient therapeutic programs (OTP) in

Al-Qanawis district of Hodeidah, Yemen

2.2 SPECIFIC OBJECTIVES To determine coverage of OTP in Al-Qanawis district

To identify factors influencing positively and negatively on OTP coverage in Al-

Qanawis district

To develop feasible recommendations to improve the coverage and outcome of

CMAM intervention

To build capacity of SCI nutrition team and other partner’s on SQUEAC

assessment methodology

2.3 EXPECTED OUTPUT SQUEAC assessment report of Al-Qanawis district

SCI nutrition team able to conduct SQUEAC assessment in other project areas

Emergeny Nutrition Program Manager

Health and Nutrition Coordinator

HIS Officer

Nutrition program Officer

Nutrition project Assistant

Mobile team 1

one Team leader

Two Nurse

COWs 25

Mobile team 2

one Team leader

Two Nurse

COWs 30

Community mobilization

officer


2. METHODOLOGY

3.1 SEMI-QUANTITATIVE EVALUATION OF ACCESS AND

COVERAGE (SQUEAC)

The SQUEAC methodology was used applying the three principles of the methodology

namely iteration, triangulation and sampling to redundancy.

Stage 1: Identification of potential areas with high and low coverage was done using

routine program data. In this stage, triangulation of data was done by various sources

and methods as highlighted below

Sources of data:

o Quantitative data was obtained by analysing OTP cards and the CMAM

data base.

o Qualitative information was obtained from care takers (of children under

treatment and defaulted children), OTP staffs, religious leaders, village

leaders, teachers, groups of men, groups of women, traditional healers,

TBA, community outreach workers (COWs) and community members.

Methods:

o Focus group discussions (FGD)

o Key informant interviews (KII)

o Simple structured interviews

o Observation

Stage 2: Hypothesis was generated and tested using small area surveys.

Methods:

o House to house screening

Stage 3: Wide area survey conducted to determine overall coverage

Methods:

o House to house screening

The trainees actively participated in every stage and learning took place by action.


3.2 DURATION OF ASSESSMENT

The SQUEAC assessment was undertaken from 19th September-2nd October 2013. Eight

teams of two members each were deployed for the coverage assessment of 11 OTP sites.

3.3. PARTICIPANTS:

18 people actively participated during the whole SQUEAC investigation process. Twelve

were from SCI, four from MOPHP and 2 participants were from local partner NGOs.

Participants list is in annex 2.

3. RESULTS 4.1 STAGE ONE

The main objective of the first stage was to identify potential differences in coverage

among OTP sites (high versus low coverage areas) as well as reasons for coverage

success/failure using routine program data and qualitative data. Various routine

program data were obtained from OTP cards and program registers. These included

admission and defaulter trends, performance indicators such as cure rate, defaulter

rate, death rate, non-responder rate, MUAC on admission, MUAC on defaulter, length of

stay for cured, length of stay for defaulter, admission criteria and referral.

4.1.1 QUANTITATIVE DATA

Routine program data from all 11 OTP sites and their 7 satellite sites offering services

was available from February 2013 to August 2013. The data was satisfactory and

records included detailed information on OTP cards and monthly reports for each case

admitted to the OTP program.

4.1.1.1 PROGRAM PERFORMANCE INDICATORS

Program performance is measured by the program outcome data according to Sphere

standards. The majority of admitted cases were discharged as cured with very few

defaulters and death. This is due to strong community mobilization, presence of satellite

sites in faraway villages and COWs carrying RUTF to beneficiary houses if they are not

coming for follow up visits.


Figure 2: Program Performance Indicator Graph of Al-Qanawis, Feb-Aug 2013

Table 1: Comparison of Performance Indicators with SPHERE minimum Standard

Performance Indicators OTP (%) SPHERE Minimum Standard

Cure Rate 99.3 >75

Defaulter Rate 0.1 <15

Death Rate 0 <10

Non-Responder Rate 0.6

It is seen from above table that performance of OTP in Al-Qanawis is better in

comparison to SPHERE minimum standard. Major OTP indicators namely cure rate,

defaulter and death rate have achieved SPHERE minimum standards.

4.1.1.2 ADMISSION, DISEASE AND FOOD INSECURITY CALENDER

As seen in the graph below admissions were higher in February 2013 due to

accumulated cases, since the program only began in that month. In the first few months

only MUAC was used as admission criteria but starting from April WFH was also added

as an admission criterion. Moreover satellite sites also started in May which might have

contributed to increased admissions in May. Gradually the admissions decreased in July

due to the local festival Ramadan and high labour demands. Again admissions increased

in August as the festival finished.

0

15

30

45

60

75

90

105

Po

urc

en

tage

s

Performance indicators over time Feb-Aug 2013 of Al-Qanawis

% Cured

% Defaulters

% Deaths

% Non-respondants


ARI

Diarrhoea

Food insecurity

Labour demand

High Price of grain

Local Festivals

Rainy Season

Figure 3: Admission Trend Compared with Disease & Food insecurity Calendar, Feb-Aug 2013

4.1.1.3 MUAC ON ADMISSION

Figure 4: MUAC on admissions for OTP

0

50

100

150

200

250

Feb-yy Mar-yy Apr-yy May-yy Jun-yy Jul-yy Aug-yy

# o

f ad

mis

sio

n

Month

Raw Admission Data

Smoothend Admission Data

37

17

7

0

45

1 2 1 0

14

5

0 0 0

5

0 1 0 0 1 1 1 0 0 1 0 0 0 0 0 1

0

5

10

15

20

25

30

35

40

45

50

11

.41

1.3

11

.21

1.1 11

10

.91

0.8

10

.71

0.6

10

.51

0.4

10

.31

0.2

10

.11

0.0

9.9

9.8

9.7

9.6

9.5

9.4

9.3

9.2

9.1

9.0

8.9

8.8

8.7

8.6

8.5

7.7

# o

f A

dm

issi

on

MUAC (CM)


In the above chart, blue bar diagrams indicate MAUC on admission and red bar diagram

indicates median MUAC on admission. The graphical presentation above shows that

majority of children were admitted in early stage of malnutrition. The median MUAC on

admission was found to be 110mm. This is an indicator of good community mobilization

for early case finding and admission.

4.1.1.4 ADMISSION CRITERIA

Figure 5: Admission Criteria

It is seen from the above chart that most of the children (71%) are admitted using

weight for height. This is due to recording WFH if a SAM child has WFH <-3SD and

MUAC<115mm.

MUAC 29%

WFH 71%


4.1.1.5 REFERRAL

Figure 6: Referral Criteria

It is seen from the above chart that most of the SAM children are referred by community

outreach workers, while 39percent care takers have brought their SAM children to OTP

themselves. It indicates some level of awareness amongst the community of

malnutrition and the CMAM program.

4.1.1.6 LENGTH OF STAY FOR CURED CHILDREN

It is seen from figure 7 below that the median length of stay for cured children was 6

weeks. The majority of children were cured by 8 weeks which is a sign of early

admission and good community mobilization.

But at the same time there are also some children who are staying longer in the

program for more than 12 weeks up to 21 weeks.

Community out-reach

worker, 61%

Self, 39%


Figure 7: Length of stay for cured children in OTP

In above chart red bar indicates median length of stay for cured children and blue bars indicate

length of stay for cured children.

4.1.1.7 OTP-SPECIFIC DEFAULTER RATE

Figure8: OTP-Specific Defaulter Rate

Overall defaulter rates in Al-Qanawis district are very few. There are defaulters only in

one OTP where community outreach workers (COWs) are relatively inactive and

villages are very far from the centre. In other OTPs, there are no defaulters because

COWs of these OTPs carry RUTF to the house of care takers if any children do not come

0 6

15

81

43

56

38 35

13 15 8

14

5 6 7 14

10 3 4

0 4

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

# o

f cu

red

# of weeks

.00 .00 .00

2.857

.00 .00 .00 .00 0 0 0 .00

.500

1.00

1.500

2.00

2.500

3.00

DEF Rate


for follow up visit, SCI has also conducted satellite sites in far-away villages to reduce

defaulter and increase coverage of the program.

4.1.1.8 OTP-SPECIFIC NON-RESPONDER RATE

Figure 9: OTP Wise Non-Responder

It is seen from the above chart that very few children are reported as non-responders.

2.1.2 QUALITATIVE DATA

Qualitative data was collected using different methods and was triangulated with

different sources. The commonly used methods were focus group discussions, semi

structured interviews and simple structured interviews with key informants in the

community.

2.1.2.1 LOCAL TERMS FOR MALNUTRITION: Marasmus: Haser, Yabas, Yarhem, Majahtato, Nashfo, Ajos (old face), Mogartato

Kwashiorkor: Moramo, Koolee, Manfokh, Madabdabo, Aafsho

00.20.40.60.8

11.21.41.61.8

2

0 0 0

2

0 0 0

1

0

1

0

% o

f N

R

OTP


2.1.2.2 KEY ACTORS IN THE COMMUNITY:

Table2: Key actors of Al-Qanawis

Village leaders Government health workers

Traditional Birth Attendants (TBAs) Religious leader

Traditional healers Grand mothers

Village committee Sheika

Community Outreach Workers (COWs) Group of Men

Group of Women Teachers

OTP staffs

Almaamon

Immam

Women initiative group/ NGO

Care takers of beneficiaries

Aqel

Quran reader

Village health committee

Qualitative data was collected from the above mentioned key actors by using different

qualitative data collection methods from different catchment areas. Data was further

organized using the BBQ (Boosters, Barriers and Questions) approach which uses three

panes to record the information as follows:

(1) Boosters,

(2) Barriers and

(3) Issues that need more investigation listed as questions.

2.1.2.3 DESCRIPTION OF BARRIERS The table below includes a description of some of the most pertinent barriers found in

the community while gathering the qualitative data.

Table 3: Community barriers leading to non-attendance, dissatisfaction with CMAM services

and defaulting

Barrier Description

No enough RUTF in some

OTP sites

RUTF was supplied to all OTP sites on an equal basis by the

government office but there was no monitoring

mechanism. So some OTPs with high admission

experienced RUTF stock out.

Long distance Some villages were far from OTP sites and very hot, dusty

wind had discouraged care takers to take their

malnourished children to OTP sites.

Inadequate awareness

about malnutrition and

Some people in the community were not aware of the

causes of malnutrition, the availability of CMAM services


CMAM services and its importance, especially for people living far away

from OTP sites. The majority of traditional healers were not

aware of CMAM services and the activities of COWs

working in that areas

Alternative health services preferred

Some caretakers still have beliefs about traditional healers and kuran and so they took their malnourished children to traditional healers and kuran readers. Traditional healers treat malnourished children by burning different parts of body, removing teeth, cutting forehead etc. Care takers also refuse to go OTP as they believe that RUTF cause diarrhoea. Sometimes OTPs are often closed which discourages caretakers to go OTPs.

OTP sites not safe Care takers were not willing to go to the OTP sites as some

OTP sites were running in old cracked buildings, some OTP

sites were running in cow sheds or dirty places. So, the

community were not feeling comfortable to go for OTP

services

COW less equipped Some of the COWs had finished their referral slips and did

not have MUAC tape. Some COWs were also not measuring

correctly so the community did not fully trust them.

Bringing RUTF to

beneficiary houses

COWs were bringing RUTF to house of beneficiaries when

they were absent. This created dependency among the care

takers and so now care takers did not intend to go to OTP

sites for follow up visits as they expect that COWs will bring

RUTFs to their house.

On a positive note, there was strong community mobilization, active community

participation, good record keeping, presence of satellite sites in faraway villages, good

awareness of malnutrition and of the CMAM activities.

2.1.2.4 CONCEPT MAP All the boosters were written in green colour and barriers with red colour on meta-

cards and their relations were linked with coverage. Stronger boosters and barriers

were interlinked with thicker lines and weaker boosters and barriers were linked with

thinner lines by the participants. This helped us to understand the strength of boosters

and barriers for coverage and prioritise the action points to improve the coverage of

program.


Figure10: Concept Map used to analyse qualitative data

3. SMALL AREA SURVEY/STUDY In this stage, the qualitative data gathered above was analysed, validated and then used

to develop a formal hypothesis. This was tested using small area survey.

3.1 HYPOTHESIS INFORMATION

Data on admissions and qualitative information indicated a possible relationship

between distance and the number of admissions. We wanted to test this hypothesis to

see whether distance indeed affected the coverage and if in close by villages the

coverage of malnourished cases would be higher than in the far away villages. To test

this hypothesis, 4 OTPs were randomly sampled and 4 villages were selected near to the

OTPs (<3km) and 4 villages far away (>3km) from OTPs. All 4 nearby villages were

visited but only 2 faraway villages were visited due to inaccessible roads.

3.1.2 Small Area Survey Finding Table 4: Analysis of findings for hypothesis testing of coverage estimation

Close by Zones (<3km) Far away Zones (>3km)

SAM cases in the program 15 SAM cases in the program 4

SAM cases not in the program 1 SAM cases not in the program 4

Total cases found 16 Total cases found 8


Coverage standard 50%

Decision rule - close by villages 8

Decision rule - far away villages 4

Out of 16 children more than 8 need to be

covered by the program for confirmation.

Out of 8 children, more than 4 children

need to be covered for confirmation.

As 15 is > 8; this part of hypothesis was

confirmed. Therefore close by villages

have higher coverage.

As 4 is not> 4; this part of hypothesis was

confirmed that coverage is less in faraway

villages.

Given the above results, it was concluded that coverage is lower in faraway villages and

higher in nearby villages for OTP. So, distance is a factor affecting coverage in Al-

Qanawis district

4. WIDE AREA SURVEY

4.1 DEVELOPING PRIOR

The prior was developed from a mode of weighted boosters and barriers

Boosters and Barriers were valued according to the weight they contributed to

coverage. Participants provided weight with scores ranging between 0 and 4.5 to each

booster and 0 to 2.7 for each barrier on the basis of their importance for coverage. The

average of those weights was calculated, as are shown in the table below. Thereafter,

the boosters were added to the minimum coverage (0%) while the barriers were

deducted from the maximum coverage (100%) and then the mean value of the two was

calculated.


Table 5: Weighted Boosters and Barriers

Boosters Weight Barriers

Good knowledge of COWs about CMAM Project

4.5 2 Over crowded

Community happy about the mobile team performance

3 1.5 Want to admit all children to OTP

Large number of children coming for services from the community

4 2.5 Poor awareness about CMAM services

Good attitude of community leaders for CMAM

4.5 2 Some of the COWs bring the RUTF to beneficiary house

Small catchments area ---less distance, easy for COWs to cover all area

4 2 No money for laboratory investigation and transport

No Stigma about malnutrition 4 2 Some mother complained about bad behaviour of health workers like shouting

No problem or religious issue regarding RUTF

4 2 Distance to OTP services

Improvement & weight gain of the children in the program

4.5 1.5 No enough RUTF in OTP sites

Change of mothers behaviour about malnutrition when they observe the improvement of their child

4 1.5 Mother perceived that mobile and MOH team discriminate some patient from other as their children are not admitted in program

Good treatment & behaviour of mobile team with beneficiaries

4 1.5 Staff not sufficient in each mobile team

Home visits of COWs to every Households 4 2.5 Some mobile team sites are in dirty, old cracked building with high risk of falling down

Free services encourage community to come 4.5 1.5 Very hot climate

Community leader follow up and monitor the CMAM program

4 1 Village is discriminated from local government authorities so, care takers do not prefer to go OTP services

There are educated mothers in some villages 3 1 There is no benefit of RUTF for some children

Successful experiences shared by mothers 4.5 2 No available essential drugs in the OTP sites

Community leader supported mobile teams to solve problems

4.5 1.5 Lack of awareness about malnutrition

No absence 4 0.5 Rich people do not want to go OTP as they feel shame that their children are malnourished and community will know that

CMAM services near to village 4 1 The conflict between villages people don’t allow them to come to the OTP sites

Good relationship among mobile teams and COWs

4 0.5 SC site refused to accept some cases referred from OTP site.

Good coordination between local council and mobile team

4 1.5 Some care takers do not COWs allow for frequent measurements of their children during house to house screening

Appreciation by the community member and community leader about the volunteers

4 2 No medicine for mothers and children with other health problems


0.5 Mobile team do not share with the health workers about selection of COWs & do not provide them information

2 The transportation is not enough for the COWs to visit all the catchment areas

1 The defaulters are not followed by COWs & mobile team

1 Female COWs workers feel shy to share malnutrition information with community males

1 No referral slip and other tools given from COWs for the beneficiaries

1 Do not give priority to care taker who came from far place.

1.5 Malnourished children do not attend to the health facility immediately as they go first to traditional healers, Kuran.

2 Sometimes all COWs are selected from same village so no COWs in another villages

1 No monthly review meeting or even every 3months among volunteers and mobile team to discuss CMAM activities.

0.5 Some health facility closed (not open always) or the health workers are absent.

0.5 Some COWs do not measure MUAC accurately.

2 Some mothers said that RUTF cause diarrhoea and sickness

0.5 Some people not trust volunteers MUAC measurement.

0.5 There’s a stigma with malnutrition

0.5 One health worker said that the mobile team not allow him to work with them.

2 Mobile team do not invite the community leader to participate in awareness of CMAM program in their community.

Sum of boosters 85 51 Sum of barriers

Sum of booster added to minimum coverage 0+85 100-51

Sum of barriers subtracted from maximum coverage

85 49

Total average 67

Prior Coverage 67%

Before using a Bayesian Coverage Estimate Calculator to represent our prior coverage,

we had discussed with the team about the possible minimum coverage and possible

maximum coverage in study area. The team believed that the coverage could not be

below 45percent as indicated by the findings or higher than 85percent since there were

some barriers to coverage. Using Bayesian Coverage Estimate Calculator, the prior was


set at 67% with alpha- 26.9 and beta- 13 corresponding to our histogram prior with

precision 10percent as shown below.

Figure 11: Prior Distribution

4.2: METHODOLOGY FOR WIDE AREA SURVEY

4.2.1 SAMPLING

Since there was no reliable map for Al-Qanawis district, systematic random sampling of

villages was done. Out of 67 villages, 16 villages were selected by the systematic

random sampling method to determine the coverage of OTP. To match the strength of

the prior, the teams were aiming to find approximately 42 SAM children.

4.2.2 DATA COLLECTION AND ANALYSIS

The teams used house to house survey techniques to find all or nearly all SAM cases in

the sampled villages to estimate the coverage and confirm the prior. MUAC and oedema

of the possible malnourished cases were checked and a semi structured questionnaire-

annexed to this report-was administered to care takers of non-covered cases. Specific

local definitions of malnutrition and aetiologies were used to ask community members

to bring the survey team to possible malnourished children. Identified SAM cases were

categorized as


i) SAM cases in the OTP program: Child with MUAC <115 mm or bilateral

pitting oedema in the OTP program

ii) SAM cases not in program: Child with MUAC <115 mm or bilateral pitting

oedema and not in the OTP program

iii) Recovering cases for OTP: Child with MUAC ≥115 mm or no bilateral pitting

oedema and in the program to attain discharge criteria

Table 5: House to house screening Results

Recovering

cases

SAM in Program SAM not in

Program

SAM 30 27 21

During the wide area survey, 48 SAM and 30 recovering cases were found as shown in

above table. From the Bayesian coverage estimate calculator (Version 3.01), the

posterior point coverage for OTP was determined at 61.6percent with credibility

interval (CI 50.9%-71.0%) as shown below.

Figure 11: Posterior Coverage Estimate for OTP


Estimated coverage for OTP is higher than SPHERE minimum standard of 50percent for

rural village settings. Further investigation on the reasons why the SAM children were

not enrolled in the program was done during house to house survey and the results are

as follows;

Figure12: Reasons for SAM cases NOT in the program, Al-Qanawis

We can see very clearly from the above chart that main reasons for the SAM children

not being in the program is distance, followed by previous rejection and inadequate

awareness.

0 1 2 3 4 5 6

Distance to OTP

Previous rejection due to under age

Lack of awareness about program

Care takers perceived descriminated by staffs

Due to pregnancy unable to carry child

Relapse

Not screened after Eid

Child refuse to eat RUTF

Alternative health service preferred

6

3

3

3

2

1

1

1

1

# of SAM children

Re

aso

ns

for

do

no

t at

ten

din

g O

TP


4. DISCUSSION The SQUEAC assessment of Al-Qanawis determined 61.6percent (CI 50.9%-71.0%)

coverage for OTP which is above SPHERE minimum standards for rural settings and the

program displayed some clear strengths and good practices. The main reason for this

level of coverage is due to the decentralized CMAM services, strong community

participation and mobilization. There are 11 OTPs in health facilities and 7 satellite sites

in villages far away from the HFs. The OTP program is integrated with the government

health system and SCI has assigned 2 mobile teams to support government staff for the

implementation of OTP. The government has identified five community outreach

workers (COW) for each OTP and they are screening almost all 6-59 months old

children at least once a month in their catchment areas and they refer SAM children to

the OTP program. This decentralization has contributed to better access, rapid

distribution of rations and decreased waiting times in OTP for beneficiaries. They are

also disseminating key messages of malnutrition and CMAM periodically. The majority

of community members have appreciated the behaviour of health workers and are

satisfied with the services provided.

There is almost zero defaulter and very high cure rate for OTP programs and the main

reason for this is that COWs carry RUTF to the beneficiaries’ house if they are not

coming for a follow up visit. In the beginning of project this was looking good, but now

staff has realized that it has created dependency among the community members and

they prefer not to go for follow up visits as RUTF is brought to their home by COWs.

This is one of the main challenges for OTPs in hot, windy and dusty rural communities

of Al-Qanawis. The team has developed a strategy that now COWs will take RUTFs to

beneficiary houses when they are absent for the first time and convince care takers on

the importance of attending follow up visits and ask them to come for next follow up

visit. This will hopefully decrease the dependency among the community.

During field visit it was found that some of the community members are not willing to

go OTP even though their children are malnourished. This is because they have

perceived that OTP staff discriminate against them and reject their children. After deep

exploration, it was found that some care takers brought their healthy children to OTPs

for admission but those children did not meet the admission criteria. So, nutrition

workers refused to admit those children as they did not meet criteria but this was not

communicated properly to caretakers. So, caretakers perceived that their children are

discriminated by OTP staff and now they are not willing to go OTPs even their children

are malnourished. OTP staff should counsel care takers carefully and transparently

focusing on the reason for admitting only SAM children before rejecting any children’s

admission.


5. RECOMMENDATIONS These recommendations are made on the basis of observations made in the community

and the findings of the SQUEAC assessment.

Strengthen Community Mobilization: It was found that still some people are going

to traditional healers, Kuran readers or private pharmacies for the treatment of

malnourished children and that they are not aware of the CMAM services. Some

mothers have refused to go for follow up as they perceive that RUTF causes

diarrhoea. Some communities have also perceived discrimination when their non-

SAM children were not admitted in OTP and sent back to home without RUTF. So,

Community mobilization activities should be strengthen to raise awareness in the

community on the causes of malnutrition, key messages of CMAM services,

admission criteria and the importance of follow up visits for growth and

development of their children. OTP staff should focus on counselling, especially for

care takers whose children were not admitted and were sent back home when their

children were not identified as SAM.

Regular Supply of RUTF and routine medicines: It was found that some of the

OTPs did not have RUTFs and routine medicines and the district nutrition managers

were saying that they have distributed RUTF equally to all OTPs. But actually

admissions in all OTPs are not same. So, RUTF and routine medicines should be

distributed on the basis of need and availability of supply should be monitored

regularly by the district nutrition manager and SCI nutrition officers to ensure

availability of all supplies for the smooth running of OTPs.

Rearrangement of catchment areas to the nearest OTP in coordination with

village leaders and local government authorities: During qualitative data

collection, it was found that some villages are far from the assigned OTP sites and it

is difficult for patients to go for follow up visits. They are in fact nearer to other OTP

sites. So, it should be rearranged so that patient attend the nearest OTP in

coordination with village leaders and government authorities.

Conduct quarterly mass screening: It was found that some malnourished children

were missing and were not screened. So, it would be better to conduct mass

screening campaigns on a quarterly basis and use all anthropometric assessments to

catch SAM children using MUAC, Oedema and WFH. This will contribute to better

coverage of the CMAM program

Ensure supply of MUAC tapes and referral slips: It was found that some of the

COWs did not have MUAC tapes and referral slips and it was difficult for them to

continue their jobs of regular screening and referral. So, there should be sufficient


supply of MUAC tapes and referral slips and each COW should be provided with at

least 2 MUAC tapes as back up.

Comfortable waiting area: It was found that some of the OTPs were running in

very old cracked buildings, cow sheds and dirty places. So, community people did

not comfortable taking their children to OTPs as they thought that their children

might get infected or building might fall down. Therefore, OTPs should be conducted

in safe and clean places which will encourage the community to come for services.


ANNEXES

Annex1: Sampling Frame

S.N. Name of OTP/SFP Village/Settlement

1 Deer Al-tabeesh

DeerAlshamee

Mahel Alhrazee

Deer Altabeesh

2 Deer Al-zaeen

DeerIbrahemm

Deer Alshalp algarpy

Almagaad AlGarbee

DeerAlzeen

Deer almaaroof

Deer Salem

3 Al-Jelaneah

Deer Mohamed Hadi

Mahel Alhendee

Mahel Showk

Mahel Saweed

DeerAlhelalee

Almahadah Algarbee

Almahadalh Alsharkee

Alkaleel alsharkee

Alkaleel algarpee

Alapas alsherkee

Alkhulaeya

Aljelaneh

4 Wadi Al-husainiah Albargee

Alkabree

5 Deer Al-sharfeen

DeerAlsaadee

Deer Alasswad

Deer alsharfeen Alshrgee Deer Almoalm Dahmash Deer abker

Alalak

6 Al-hazer

Alhazer

Habeel aten

Mahel Dakhan

Almahandid


Habitat ibrahim saleh

Makad alsharki

Deer Albawah

7 Deer Al-saif

DeerAlsaif

Hafees

Habeel Almwathnah

Almsbaar

Alsamah

Habel masood

Deer Aweedan

8 Deer Al-taweel

Altaweel

Deer Dabeen

Alnashad algharbi

Alnashad alsharki

Alkadri algharbi

Akadri alsharki

Almakadel

DeerAlbasoot

9 ALANWASH Alanwash

10 Al-gham Al-gharbi DeerAlgahm Algrbee

11 Doghan

Alskban

Alkaroos

Almadafen

Alanid

Almadbar

Almuneeb

Aljallah

Almakafee

Alhalag

Zabeed Alsharki

Kaola

Bo alagaia

Doghan


Annex2 List of Participants

No Names of Participants Postion Orgnaization

1 Adel Qasem Othman Saeed statistic department GHO- Hodeida

2 Abol-geth Shwgee Yahia Gaadree Alqnawes nutrition coordinator GHO- Hodeida

3 Abol-geth Mohamed Ahmed Abdullah deer Altabesh HFs manager GHO- Hodeida

4 Abdullah Hassan Alkuple Nutrition Assistant GHO- Hodeida

5 Reem Abo Baker Yahia Almazgagy child project officer CSSW (Local NGO )

6 Mona Omer Suleman child project officer Tawasel (Local NGO )

7 Dr Mariam Abdurabo Aldoghani Health & Nutrition coordinator SCI

8 Boto Ali Ibraheem Showk HIS Officer SCI

9 Qasem Ahmed Qaleb Almaqtaree Community mobilization officer SCI

10 Ramla Ali Hajj Othman Nutrition Officer SCI

11 Fatima Suleman Zaed Alhakamee Mobile team OTP Officer SCI

12 Dr Baha Alden Thabet Alsalwee Nutrition Team Leader r SCI

13 Omer Yaha Abdulhadee Mobile team OTP Officer SCI

14 Ahmed Huseen Motaher Alashmoree Nutrition Project Assisstant SCI

15 Maha Zayad Saleh Nutrition Project Assisstant SCI

16 Dr Sawsan Saif Ahmed IYCF Officer SCI

17 Sebsibie Teshome Nutrition Program Manager SCI

18 Kiross Tefera Nutrition Advisor SCI


ANNEX3 ACTIVE ADAPTIVE CASE-FINDING PROCEDURE

Ask in the community for a guide/informant to show you houses with oedematous, thin and sick

children and children in the program

Ask the guide to take you to houses with oedematous, thin and sick children and children in the

program.

Go to the first household identified by the guide or the leader.

We are looking for children in the programme and SAM children not in the programme

When you arrive at an identified household, introduce yourselves, the program, and explain why you

are there and what you will be doing. Then start assessing the child.

Is the child between 6-59 months of age? To confirm the age ask for vaccination card and calculate

the age in months (if no card use calendar of events to calculate the age of the child)

No

Thank the career and ask the mother of

this child if she knows of any children

that might be oedematous, thin or sick,

or in the program. Then move on.

Yes

Check Oedema, take MUAC

The child has bilateral oedema or MUAC < 115 mm?

If yes, is he in the OTP programme?

If not, is he in the OTP programme? (not a case)

No (for cases not in the

programme)

Fill the form then fill up the

questionnaire for children who are

not in the program and refer the

child to the appropriate programme.

(Refer to CSt children with oedema

and WfH <70% i.e. marasmic-

kwashiorkor)

Yes

Fill the form

Thank the mother, and ask her if she knows of any

children that might be oedematous, thin or sick, or in the

program.

Then move on


Remember

1) After you have assessed the children in the selected household, always ask the mother if she

knows of any children that might be oedematous, thin or sick, or in the program. Then move on to

the selected household.

2) Always ask if any child from the village is currently in hospital or at a health centre. If so, get the

name of the child and mother and make sure you measure him / her in the health facility.

3) If a mother with oedematous, thin and sick child is away from the village, go where she is and

measure the child.

4) If a mother with a child in a program is away from the village, take the name and age of the child,

verify in the OTP register


Annex 4 Qualitative data collection guideline

1. COMMUNITY - LAY PEOPLE

The discussion should flow naturally and leads/interesting points should be followed/explored

as they come up. The question list should not be rigidly adhered to. This is just a guide as to the

kind of topics which are important and the type of questions which could be asked. The

direction the discussion takes will depend on what is said by the participants. It is always

important to probe and ask follow up questions.

UNDERSTANDING OF MALNUTRITION

1. What are the common health problems that children experience here?

2. Which are the most frequent? Rank.

3. Are any more frequent at certain times of the year? When? Why?

4. Which are the most serious? Rank. Why?

If malnutrition mentioned ask:

5. What symptoms do these children have?

6. What terms do you commonly use to describe this condition?

7. Which children get this condition? Why?

HEALTH SEEKING BEHAVIOUR

8. What do you do when your child has this (insert name of most common illnesses)

problem?

a. Probe fully for different illnesses

9. What factors determine which treatment / approach you use for a particular illness?

Probe on:

a. Cost, Access, Father permission, Habit/familiarity

If clinic/hospital mentioned:

10. Which? How far is it? Why do you go there?

11. Is there any alternative/anything else you might do/anyone you might ask for

advice nearer home?

If malnutrition not already mentioned ask/show pictures:

12. Have you seen children like this (those who have lost weight/become very thin or

whose feet/legs/hands have started to swell?

13. When do you see this condition? Are there children who have this problem now?

14. What do you call this condition?

15. Which children get this condition? Why?

16. What do you do when your children get this condition? Why?

AWARENESS OF CMAM SERVICE

17. Do you know of a place where this condition can be treated?

18. How did you hear about it?


a. Who told you? When? What do you know about it?

19. What are children given for this condition?

If people think the RUTF is a food asks:

a. What sort of food is it?

b. What do you call it?

c. Who can eat it?

d. What foods do you give your children to make them health/strong?

20. Do you know children receiving this treatment?

PERCEPTIONS OF CMAM

21. What do you think /what are people saying about this service?

If people say it is good ask:

a. What is good about it?

22. Have you noticed a change in the children who are being treated?

23. What improvements would you like to see to the service?

If people say it isn’t good ask:

a. What is wrong with it?

24. What do people not like about the service?

25. How can we change it? What suggestions do you have?

AWARENESS OF CHW/VOLUNTEER (CASE FINDER) AND HIS/HER ACTIVITIES

26. How are children identified for treatment?

a. What tool is used?

b. Have you seen anyone doing this in your community?

If people know the volunteer/have seen the MUAC ask:

c. When was the last time you saw the volunteer measuring children? How often

does he do it?

d. How are children referred to the health centre?

If not, show the MUAC tape and repeat questions if necessary:

COVERAGE QUESTION

27. Do you know children who have this condition but who are not going to the health

centre for treatment? Why?

28. Do you know of any children who have stopped going for treatment?

a. Why is this? What would encourage them to return?

29. Do you know of children who have been to the clinic and have not been given the

treatment?

If yes,

a. Why not? What were they told? How did they feel?

BARRIERS


30. What factors might prevent children from being able to access treatment? Why?

How can we overcome these obstacles?

31. What messages/suggestions would you like us to pass to the people running the

CMAM service?


2. Key community figures (local village/religious leaders)

Open questions about the situation in the village / the health of the children etc. can always be

asked of the leaders at the start before focusing on the issues of interest.

Understanding of malnutrition

Health seeking behaviour

KNOWLEDGE AND UNDERSTANDING OF CMAM

1. Are you aware of any nutrition service at your local clinic?

2. Who told you about it?

3. When did you hear about it?

4. What do you know about it?

a. Target children? (ensure both marasmic and kwashiorkor types are identified)

b. Admission criteria?

c. Treatment given?

d. OTP day?

e. Identification of children?

ROLE / AWARENESS RAISING

5. Have you been involved in telling others about the service? How? When?

PERCEPTIONS OF CMAM

6. What are people saying about CMAM?

a. Do you think most people are aware of it?

b. What do they understand about it?

7. What do you think of the service?

a. What do other key community figures think of it?

BARRIERS/COVERAGE QUESTION

8. Do you know any children currently receiving treatment in the village?

a. What can you tell me about them?

9. Are you aware of any children who need treatment but are unable to access

services?

a. What stops them coming? (distance/family/beliefs/other)

b. How could we reach these children/encourage them to attend?

10. Do you know any children who have defaulted/stopped coming?

a. Why is that? How can we encourage them to return for treatment?

STIGMA

11. Is there a stigma attached to malnutrition in your village? Are there parents who

might hide their malnourished children? Why?

COMMUNICATIONS

12. Do you know anyone in the village who identifies children for this service?

a. When did you last see them? When were they last active?


b. What do they do? (frequency and organisation of activities = passive or active)

13. Have you had any feedback from the volunteer/clinic staff/MoH officials about the

service?

14. Do you know what the results are (number of children cured)?

IMPROVEMENTS

15. How can we improve the service?

16. Do you have any messages for those who run the service?


3. TRADITIONAL HEALER / OTHER HEALER

TREATMENT AND PERCEPTION OF MALNUTRITION

Start the discussion by asking:

1. What types of illnesses do you treat? Most common? How many patients do you see a

week?

2. How do you treat this illness? What do you do if the treatment is not effective?

If not mentioned show picture of malnourished children and ask:

3. Do you see children like this in the village? Do you treat this illness? How do you treat

this illness? How often do you see it and when? What are the causes of this illness? How

effective is the treatment?

4. Are you aware of any other treatment for this condition?

Continue with similar questions asked of key community figures starting with awareness of the

service

KNOWLEDGE AND UNDERSTANDING OF CMAM

1. Are you aware of any nutrition service at your local clinic?

2. Who told you about it?

3. When did you hear about it?

4. What do you know about it?

a. Target children? (ensure both marasmic and kwashiorkor types are identified)

b. Admission criteria?

c. Treatment given?

d. OTP day?

e. Identification of children?


4. CARERS OF BENEFICIARIES

Individual case history

HISTORY OF THE ILLNESS

1. When did you first notice that your child was unwell?

a. What was wrong with them? What symptoms did they have?

b. What was the cause of the problem (probe for illness / food availability)?

HEALTH SEEKING BEHAVIOUR

2. What did you do when your child became ill?

3. Did anyone tell you to go to the health centre (information source)?

4. How long was it before you went to the health centre?

INFORMATION SOURCE FOR THE OTP

5. How did you first hear about the service?

a. Who told you?

b. Have you heard about it from any other source since?

c. Who is telling people about it in your settlement?

6. What did you hear about it?

7. What made you come?

AWARENESS OF/CONTACT WITH CHW/VOLUNTEER (CASE FINDER)

8. Did your child have his/her arm measured at home (MUAC)?

a. By whom? How was it done? What did he/she tell you about it?

b. When was the last time your child was measured at home?

UNDERSTANDING OF THE SERVICE

9. What did the clinic staff tell you about your child’s condition?

10. What were you told about the treatment? (Check understanding of procedures,

approximate length of treatment, what to do if you need to travel, sharing of RUTF

etc.?)

11. What does the staff call the treatment? What do you call the treatment?

STANDARD OF SERVICE

12. How long do you usually wait before the nurse sees you?

13. How much time do you spend with the nurse?

a. How do the staffs treat you?

b. Have you ever been scolded? Why?

14. Have you always received the correct supply of treatment sachets?

a. Have there been any shortages on any week?

b. Have you ever not received the full amount / or received something else

instead?

OPINION OF THE SERVICE



a. What are the strengths/weaknesses?

b. Difference in the health of your child?

c. What could be improved?

ABSENCE/DEFAULTING

16. How easy is it for you to come every week?

a. What makes it difficult / stops you from coming sometimes?

17. Do you know of any children who have stopped coming?

a. Why is that?

b. How can we encourage these children to return and continue the treatment?

COVERAGE QUESTION

18. Do you know of other children who have the same problem but who are not

attending the clinic?

a. If yes, why not?


Group discussion with carers

INFORMATION SOURCE FOR THE OTP

1. How did you first hear about the service?

a. Who told you?

b. Have you heard about it from any other source since?

c. Who is telling people about it in your settlement?

2. What did you hear about it?

3. What made you come?

AWARENESS OF/CONTACT WITH CHW/VOLUNTEER (CASE FINDER)

4. Did your child have his/her arm measured at home (MUAC)?

a. By whom? How was it done? What did he/she tell you about it?

b. When was the last time your child was measured at home?

STANDARD OF SERVICE

5. How long has your child been receiving treatment?

6. Difference in child’s condition?

7. Have you had any difficulties in following the treatment/attending every week? (Probe

for: distance, waiting time, welcome, etc.)

8. Have you missed a week? Why?

9. Have you always received the correct supply of treatment sachets?

a. Have there been any shortages on any week?

b. Have you ever not received the full amount / or received something else

instead?



a. What are the strengths/weaknesses?

b. What could be improved?

DISTANCE

11. How far is it from your home to the clinic?

a. How do you get here? Walk/transport?

b. How long does it take?

c. Determine the farthest distance travelled within the group

12. Do you have any other reason to come to this clinic/this place?

COVERAGE QUESTION/DEFAULTING

13. Do you know of any children who have stopped coming?

a. Why is that?

b. How can we encourage these children to return and continue the treatment?

14. Do you know of other children who have the same problem but who are not attending

the clinic?

a. If yes, why not?


b. What would encourage them to come?

CASE REFERRAL

15. Have you told anyone else to bring their child to the clinic?

a. Why/why not?

PERCEPTION OF CMAM

16. What are people saying about the service in your settlement?

17. Are the other mothers aware of the service?

STIGMA

19. Is there a stigma attached to malnutrition in your village? Are there parents who

hide their children? For what reason?

If stigma exists:

20. How does the stigma affect you personally? In what way?

FEEDBACK

18. Have you any messages you want us to give to the people running the service?


5. VOLUNTEERS

ROLE

1. How long have you been a volunteer?

2. What are your main activities?

3. How often do you do these activities?

4. What area do you cover for case finding?

a. How long does it take you?

5. How do you decide which children to measure?

6. What tools do you have to help you?

7. Tell me about the last case you identified? When was that? What was the problem?

EXPLANATION GIVEN TO MOTHERS

8. What do you tell the mother when you identify a case?

9. What do you say about the new treatment?

10. How do you refer to the treatment?

a. What do the mothers call it?

REFERRAL AND FOLLOW UP

11. Do you give the mother a referral slip/paper when you refer the child to the clinic?

a. Why/why not?

b. How do you know if the child actually went to the clinic?

12. Are you aware of any children who have stopped coming?

a. Why is that? How can we encourage them to return?

13. Are you ever asked to visit a case that is not improving / has been absent? Tell me

about the last one you visited.

REJECTION

14. Have you referred any children who have been turned away and not given

treatment?

a. For what reason? How many were rejected last month?

b. Did you receive an explanation from the nurse as to why?

c. How did the mother react?

d. What was your reaction?

15. Are you aware of any other children who went spontaneously to the health centre

and were turned away and not given treatment? Probe: a-d as above.

COVERAGE QUESTION

16. Do any mothers refuse to go to the clinic? Why? How can we encourage them to

bring their children?

COMMUNICATIONS

17. When was your last contact with clinic staff?

18. Are there regular monthly / 3 monthly meetings with health centre staff? Are CMAM

issues discussed?


19. Do you have a monthly written/verbal report to make on your activities (number of

children identified, number referred, home visits etc.)

20. How do you usually communicate with the nurse at the health centre (for example

when a home visit is needed)

21. Have you received any feedback from clinic staff

a. Number cured?

b. Number of defaulters? Reason?

22. Have you talked with village / religious leaders or other people about CMAM since it

started? When was your last contact? Topic of discussion?

23. Have you had any further contact with children you have referred?

a. Do you know how many were cured?

b. Do you know if any defaulted? Why?

24. What have mothers said to you about CMAM?

a. What are people saying/thinking about CMAM?

OPINION OF THE OTP

25. What is your opinion of the OTP? Why?

26. What is the opinion of the community?

MOTIVATION

27. Appreciation of your work by the community?

28. Appreciation of your work by programme staff?

29. Do you enjoy your role? Why / why not?

30. Challenges / difficulties?

IMPROVEMENTS

31. What would help you in your job as a volunteer?

32. How do you think CMAM could be improved?

33. Any messages for those running the service?


6. OTP STAFF

CMAM INVOLVEMENT AND CHALLENGES

1. How long have you been working on CMAM?

a. How many staff are involved/trained on CMAM?

2. When were you trained on CMAM?

a. Have you had refresher training?

b. Is there any additional training you feel you need?

3. What difficulties, if any, do you have on the CMAM day?

a. High number of patients

b. Time

c. Completing paperwork accurately and keeping up to date

CALENDAR

4. What are the main childhood diseases you see in the clinic?

a. Which is the most common? Rank.

b. What time of year do they occur?

5. What do you think are the causes of malnutrition here?

REFERRAL

6. How do children usually come to the clinic for CMAM?

a. Referred by volunteer

b. Heard about it from other beneficiary

c. Heard about it from other person in the village

d. Heard about it at the clinic

e. Heard via the radio/town crier etc.

f. Other source

g. Rank in order

REFERRAL AND FOLLOW UP

7. Do children who are referred by the volunteer come with a referral slip/paper?

a. What do you do with the referral slips?

8. Is there a system to check that the child referred by the volunteer has actually presented

at the clinic? System to confirm the number of referrals per volunteer?

9. How do you refer patients to the stabilisation centre? Paper slip?

a. How do you know if they have arrived at the SC?

b. Do you know what happens to them?

c. When patients are referred back do they come with any paperwork?

REJECTION

10. How many healthy children have you rejected who do not correspond to the admission

criteria?

a. How many every week?

b. Explanation given? What do you actually say/what words do you use?

c. Why do you think these mothers come with healthy children?


d. How do mothers react?

11. Have you had any wrong referrals from the volunteer?

a. How many? What was the problem? Did you report back to the volunteer?

DEFAULTING

12. How many children are absent for more than 1 week during the course of treatment?

a. Why do you think this is?

13. How many children default?

a. Why do you think this is?

14. Is there a system to follow up on defaulters? How does it work? How could we

encourage children to return for treatment?

15. What barriers prevent mothers from bringing their children to the OTP?

COVERAGE QUESTION

16. Are you aware of any children with this condition who don’t come to the CS? \Why is

that?

COMMUNICATIONS

17. Are there regular monthly/3 monthly meetings with volunteers? Are CMAM issues

discussed? How often do you see the volunteers? Last time?

18. When was the last time you saw someone from the district office? Frequency of contact?

19. Support from the district?


20. Does the OTP give good results?

21. Has the condition of the children improved?

WORK LOAD

22. Does the OTP give you more work?

23. What changes have you had to make to your routine activities?

IMPROVEMENTS (different order)

24. Challenges? Problems? Improvements?

25. What messages do you want us to pass to the people organising CMAM?


ADDITIONAL QUESTIONS (adapt according to the audience)

Terminology:

Check what terms are used to describe the different types of malnutrition.

Key people:

In your village who are the people who are in close contact with children under 5 and

can point out their houses (because they are involved in care or preventive/other

activities).

Calendars:

Ask the community to help you develop seasonal calendars for:

o The hunger gap

o Agricultural labour (periods of intense activity)

o Child illness (ARI, malaria, fever, diarrhoea etc.)


Annex 5. Survey Questionnaire for caretakers with SAM cases

NOT in the programme Ward: ___________________ Village: ________________

Child Name: ______________ Team: ___________

DO YOU THINK YOUR CHILD IS MALNOURISHED (sick, thin, have oedema on both legs)?

YES NO

ARE YOU AWARE ABOUT THE EXISTENCE OF A PROGRAMME WHICH CAN HELP

MALNOURISHED CHILDREN?

YES NO (stop)

If yes, which programmes (s)? ______________________________________

WHY DID YOU NOT TAKE YOUR CHILD TO THAT PROGRAMME?

Too far (How long to walk? ……..hours)

No time / too busy

Specify the activity that makes them busy this season __________________________

The mother is sick

The mother cannot carry more than one child

The mother feels ashamed or shy about coming

No other person who can take care of the other siblings

The amount of food was too little to justify coming

The child has been rejected. When? (This week, last month etc)________________

The children of the others have been rejected

My husband refused

The mother thought it was necessary to be enrolled at the hospital first

The mother does not think the programme can help her child (prefers traditional healer, etc.)

Other reasons: ___________________________________________________

WAS YOUR CHILD PREVIOUSLY ADMITTED TO OTP/SC PROGRAMME?

YES NO (=> stop!)

If yes, why is he/she not anymore enrolled?

Default, When......................Why?..................

Discharged cured by the programme (when? ............)

Discharged non-cured (when? .............)

Other:___________________________________________

(Thank the mother/carer)

location: al-qanawis, hodeidah, yemen date: september 2013 ... · cmam periodically by community...

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